Healthcare Reform

In early November, HealthEd answered a call for designers to “create a better patient experience” by “reshap[ing] the way health records are presented.” As with any initiative that aligns with our own passions and reflects the core mission of our company, we accepted the challenge with child-like glee.

The HealthEd team separated into 2 groups and embarked on a journey of intense effort, amazing thinking, and the kind of satisfaction that results from doing something you really love. Our submissions can be found below; both entries demonstrate how PHR can be integrated into clinical systems, yet rendered accessible across multiple formats.

Health ResumeThe Health Resume provides a holistic view of the patient’s current health. A health score determined by body, emotional, and lifestyle factors helps the patient easily identify where s/he is most healthy and where there’s room for improvement. Relevant and immediate medical data is presented in an easily consumable format for patients, caregivers, and doctors to quickly gain an understanding of the patient’s active conditions and treatments.

(click to enlarge images)

The intent of the Resume is to transfer the wealth of medical knowledge from doctor to patient in a way that the patient can understand and take informed action to improve his/her health.

Patient-Centered Design Pattern"Patient engagement" starts with patients not only accessing health information but also feeling comfortable and confident enough to act on the health information. With that in mind, the design pattern was built to support behavior change by providing strong visual flags for important information that must be acted on.

(click to enlarge images)

Standardizing how to treat patient information will ensure patients not only have access to their data but can also work successfully toward their health goals.

Whether you call them "allied health providers," "mid-level practitioners," or, as the CDC refers to them, "healthcare extenders," non-MD professionals are on the front lines of healthcare and they are only growing in importance. They're the nurses, diabetes educators, physician assistants, social workers, dietitians, respiratory therapists, and others who translate the "what" of a physician's orders into the "how-to" for patients and care partners. And their numbers are trending up.

Here are 7 reasons why healthcare organizations of all stripes need to embrace healthcare extenders and spend more time learning about their needs:

Their ranks are increasing. Amid the talk of looming physician shortages, the Bureau of Labor Statistics is projecting 20%-plus job growth for many healthcare extender job categories over the next decade. Nurses are projected to grow by 26%. Diabetes educators are projected to grow by 60%!

Demand is increasing. Not only is the US population aging, but at the same time the Affordable Care Act will be giving millions of uninsured people health coverage. Perfect storm? Many healthcare extenders are hanging up their own shingle to address the wave of new patients.

They can prescribe. Nurse practitioners have some prescribing authority in all 50 states. PAs can prescribe in 48 states. And pharmacists are providing critical prescription guidance to patients right at the point of purchase.

Patients trust them ... often more than doctors. A USA Today/Gallup poll raised eyebrows a few years ago when it found that Americans trust nurses and pharmacists more than any other professional, including physicians.

They serve as critical patient resources. Of the healthcare extenders surveyed for our report, 59% said that patients "sometimes" or "often" bring information they find on the Internet to discuss. It's not surprising, then, to learn that 82% of extenders in private practices and 60% in outpatient clinics point their patients to credible health Web sites.

They are eager to learn. Healthcare extenders are typically educators themselves, and as such they are receptive to learning about new methods and technologies. I love this quote from a cancer center nurse who participated in the HealthEd Academy survey: "We need to train the trainer first. A majority of baby boomers may not be comfortable with technology. Yet, as patient educators, they have so much valid and useful knowledge." Many opportunities there.

In a few years, healthcare extenders will be the primary users of EHR. You heard it here first. To achieve Stage 3, meaningful use, users of electronic health records will need to show patient engagement and improved outcomes. That engagement will come not from simply collecting medical data but by disseminating relevant and timely patient education—clearly the domain of healthcare extenders. Already 70% of those taking our survey said their facility will have adopted EHR by the end of 2012.

Intrigued? Concerned? Inspired? Good! You can learn more by downloading the free report, taking a quick peek at the infographic, or even contacting me to talk about getting closer to the healthcare extenders in your field.

“People tend to comprehend more and make better-informed decisions when the presentation format makes the most important information easier to evaluate and when less cognitive effort is required.”Ellen Peters, PhD, research scientist; associate professor of psychology, Ohio State University

After more than 20 years as a healthcare professional and health educator, I wonder if we have become desensitized to the weight and complexity of treatment decisions for patients and care partners. At the end of the day, patients and care partners universally ask 2 questions: “Will this treatment work?” and “What are the side effects?” It has always fascinated me that patients and care partners often ask these 2 questions even after they’ve reviewed educational materials and received counseling from their healthcare providers.

So, why are these questions so common when almost all branded websites and materials offer a “Benefits of Brand X” section?The most common approach to presenting benefits and risk information is through numerical trial data. During a recent market research interview, a patient said, “I have never heard of ‘placebo’ is this another treatment? The moderator of the interview went on to describe the placebo as a “sugar pill.” The patient responded, “does sugar help with this condition?”

Because we work with trial data every day, we forget that most patients don’t live in the world of clinical trials. To complicate matters, regulatory guidelines often require the inclusion of robust study design, which is important but only adds to the complexity and diverts attention from the information that patients and care partners are most interested in: benefits and risks.

Defining health numeracy

Peters et al (2007) define health numeracy as “an element of health literacy that refers to the ability to understand numbers.” Findings from the National Adult Literacy Survey show “almost half of the general population has difficulty with relatively simple numeric tasks such as calculating the difference between a regular price and a sales price or estimating the cost per ounce of a grocery item.” They have difficulty while using a calculator. If you add the emotional weight of treatment decisions and health challenges to this situation, it is easy to see why patients and care partners are struggling.

Here is a list of best practices for driving health numeracy when presenting benefit/risk information.

Less is more. Marketers, medical/legal/regulatory, and agencies need to work collaboratively to identify the most effective, responsible, and balanced approach to presenting what patients and caregivers most want and need to know. For example, onerous study design can be confusing and may be less important to patients. Is there an opportunity to minimize some study design or present study background in a way that does not compete with priority benefit/risk information.

Reduce required inferences and calculations. Studies have shown that percentages are difficult for patients to process and relate to. Patients struggle to see how such numerical concepts relate to their own situation, and they often misinterpret the information. Steps for simplifying calculations include:

Use ratios, and keep the denominator constant to reduce effort and increase comprehension (20 of 1000; 1 of 1000)

Choose using absolute risks (for example, 3 of 1000) will have a stroke) over using relative risks (50 percent higher chance of stroke)

Avoid using decimals

Use the same time span when expressing efficacy and risk

Use meaningful visual cues and displays to highlight the meaning of information

Summarize key information

Avoid using confidence intervals because people tend to accept or reject information fully without adjusting for data quality

Test and revise formats carefully to reduce the effects of low numeracy. Approaches to presenting numeric information should be tested with target audiences whenever possible. Without usability testing, time and resources are invested with no real guide as to whether the content will impact the target.

The decisions of people with low numeracy are likely to be informed more by non-numeric sources of information. In reality, it is NOT “all in the numbers.” Treatment decisions are also a subjective, emotional experience. It is very difficult to validate or capture these emotions through numbers. This may be one reason why patients and care partners are so active on social media portals seeking the stories and experiences from other patients and care partners.

It is important to know and involve your audience and as you develop benefit and risk communications. This can help educators and marketers to develop the optimal approach to presenting clear numerical presentation of outcomes with relatable, balanced stories of patients, care partners, and healthcare providers.

With tight budgets and aggressive brand goals, marketers needs to take a close look at what drives sales for a pharma brand. Why should patient education be a critical part of the marketing mix? Here are 5 key reasons.

It is valuable to healthcare professionals (HCPs)-Aside from samples, patient education is one of the resources most requested by HCPs from pharma sales representatives. The fact that the American Academy of Family Practioners (AAFP) has an entire section on their Web site featuring patient handouts, counseling tools, and other resources, illustrates there is a need. Also according to research conducted in late 2011 by HealthEd OnDemand, HCPs -- specifically 99% of dietitians -- consider educational materials to be important or essential. In short, having patient materials provides sales representative access to HCPs.

It drives adherence -When patients’ expectations for treatment are set up front, they are more likely to remain committed. Patients need to understand the importance of taking their medications, what the benefits will be and how quickly the benefits will come. Sometimes they can’t tell if a treatment is working. Or their treatment may not work right away. They need to know what to expect.

It helps patients effectively manage side effects– This is tied to adherence but I feel the need to call it out separately. Setting patients understanding of side effects is much more than placing safety information on materials. Side effects are one of the top reasons for patient drop off for most medications; however, if patients truly understand what to expect upfront and are prepared with how to manage, then the likelihood of drop off decreases. The phone calls to their HCP’s office also decrease which I’m sure physicians and healthcare extenders appreciate. Patient complaints about side effects can be a huge barrier to physician prescribing so focusing on the patient can have a halo effect on prescribing.

It provides accurate and understandable information-My parents’ generation still takes a physician’s recommendation at face value, doesn’t question things and doesn’t really understand their disease state or their treatments. This is no longer the case with younger generations. The baby boomers spend a lot of time online. In fact, 79% Americans age 50-64 are online. And 80% of adults who are online are looking for health information. So patients are getting information about their health and treatments but it may not be the correct information. Or it may be confusing and not health literate. Developing good patient materials ensures that patients are getting the right message about your brand.

It improves patient outcomes – This last one may sound altruistic when you’re used to thinking about brand sales; however, with healthcare reform a physician’s compensation will be increasingly based on patient outcomes. There is a link between a well-educated patient and improved health outcomes and helping physicians improve outcomes for their patients will provide the best value pharma can bring to the table. Plus, helping patients is the right thing to do for both personal and professional reasons.

What do a quasigovernmental agency and a healthcare marketing agency have in common? Patient-centeredness. You may have read about the newly established Patient-Centered Outcomes Research Institute (PCORI),which is made possible by the Affordable Care Act. This organization is working to get at the root of a conversation of great importance to patients and the pharmaceutical industry alike. How do all stakeholders—including healthcare providers, payers, care partners, pharmaceutical companies, device manufacturers, and patients—support the way patients make informed decisions that are right for them?

What are key patient questions?

PCORI is now funding pilot research projects that will help us all understand how to answer these questions that patients may ask:

Given my personal characteristics, conditions, and preferences, what should I expect will happen to me?

What are my options, and what are the benefits and harms of those options?

What can I do to improve the outcomes that are most important to me?

How can the healthcare system improve my chances of achieving the outcomes I prefer?

How can we respond?

You may be thinking that it will take time and money to learn the answers. That it is too far removed from our work every day.

However, these questions and others like them should be central to all patient education and marketing efforts. To truly help people adhere to new regimens, we need to uncover challenges they have when faced with starting a new medicine or using a new device. Patients should also fully understand their personal risks. Risk and benefit information should be simplified so that all stakeholders can make informed decisions. Patients should be able to identify the outcomes that are important to them and should know ways to discuss these with their healthcare teams.

While the PCORI research results will help us all refine our patient education and support efforts, there is no need to wait. It’s already possible to develop patient-centered materials that support these objectives.

Proven success is an eye-catching brand claim. This simple statement can instantly add credibility for a brand and build trust with patients and healthcare providers with a mere 2 words. This claim is always substantiated by the brand’s clinical research; however, as a health educator, I often question whether or not the results are sustainable long-term behavior.

I would argue that partnering claims with the support of health education can lead to sustained health behavior changes. Here's why.

I discovered health education while I was coaching consumers of a well-known weight-loss brand on the basics of nutrition and the brand-focused weight-loss products. I felt that despite all my efforts, the end result for consumers was not life changing. Consumers could use the brand’s products and achieve success, but market research showed that few consumers could sustain the weight loss over the long term.

Proven success was the brand claim. I felt challenged with this because I believed that the slogan overpromised. In my experience, the claim was based on short-term results, and using the products did not result in the behavior changes necessary to lead to sustainable weight loss for the consumers. At this moment, I recognized the need for health education—and with that, my educational approach was transformed. I started to recognize that arming consumers with nutrition knowledge was not nearly enough. Consumers simply needed more in order to understand the information and then be able to act upon it to achieve long-term success.

Applying the health education learnings and a theoretical behavior change framework helped me overcome these challenges and changed the outcomes. This change not only affected the consumers in supporting their behavior changes but also helped to grow the brand. Consumers gained the ability to self-recognize and to strategize a personalized approach to dealing with nutrition and weight issues that was sustainable over time. The brand gained heightened perceptions of results that could potentially lead to a larger market share.

Health education made the difference. There are many opportunities to apply this to healthcare products and related consumer goods. To take advantage of these opportunities and make a difference for the consumers of your brand, a health education approach may be key to proven longer-term success.

I was a precocious child. For example, when I was 5 years old, I changed my name—ever so slightly but enough to make a difference. A couple of years later, I canceled an appointment with my pediatrician. I didn’t want my doctor to talk with me about being overweight. Getting on the scale caused me great anxiety; visiting the doctor made me self-conscious and uncomfortable. Dr. Adelman told me I was too chubby and had to lose weight. Yet he always offered me a lollipop before I left the office. With every subsequent visit, I thought he was going to embarrass me about my weight. The emotional pain became so great that I avoided my appointment rather than be subjected to my doctor’s judgmental comments. Fast-forward 40+ years. I was still avoiding well-care visits. Getting on a scale still conjures up feelings of embarrassment, loss of self-control, and disappointment.

If only I ate in moderation and exercised regularly—but I do not. While I have not recently experienced the judgmental comments or nonverbal communications of my doctors and nurses, I internalized the comments and reactions of my pediatrician. As an adult, I practiced the same unhealthy behavior of many overweight women who have ignored their health due to stigma and shame. For them, that point in a doctor visit—stepping on the scale—is associated with intense negative emotions that keep too many people who are overweight and obese from obtaining proper preventive healthcare.

Treatment includes treating all people with respect

Two points I find interesting on the topic of obesity are that weight counseling in the primary care setting has decreased 1 and that there is a need to educate healthcare providers about treating obese people with respect and dignity.

At a recent conference on obesity, it was reported that physicians have not found weight counseling to be effective—one reason for the reduction in time spent on this intervention. This decrease in counseling time is occurring despite an increase in patient visits for diabetes, hypertension, and other obesity-related issues. A Healthy People 2020 goal has been set to increase the proportion of obese-adult office visits that include counseling and education on losing weight and living a healthy lifestyle. But are physicians and other healthcare providers equipped to counsel these patients? Do they have effective tools and the resources to guide their patients about weight loss?

At the obesity conference, Christopher N. Sciamanna, MD, from the Penn State University College of Medicine, said that physicians must have effective tools, including Web sites and programs, to guide the treatment of obese patients. He added that physicians need education on what to say and do to help obese patients.1 Weight counseling is not adequately addressed with a few quick statements emphasizing that a patient’s diabetes, cardiovascular disease, or arthritis will be further compromised if he or she does not lose weight. In the absence of knowing what to say and in feeling defeated because of the ineffectiveness of what has been offered, has the course of action for physicians been to say and do less?

Caring for patients with obesity

I started writing this blog when I read a statistic about the high number of women who avoid well-care visits because of the embarrassment and shame they feel about their weight. The case study I read mentioned a healthcare provider rolling her eyes when recording the patient’s weight. The article described a patient’s humiliation when the scale stopped at 350 pounds and the dressing gown was too small. I went on to read more about the challenges of treating people with obesity and realized what a learning curve it is. However, a core tenet of caring for any patient is respect; and in the case of obesity, a few basic considerations have been described in an article from the National Institutes of Health and the Weight-control Information Network (WIN). Excerpts from the article are listed below. To read the full article, go to Medical Care for Patients with Obesity.2

·Have suitable equipment and supplies on hand to improve patient access to care.

·Create a positive, open, and comfortable office space.

oProvide reading materials in the waiting room that focus on healthy habits‚ rather than physical looks or being “thin.”

·Use medical devices that can correctly assess patients with obesity.

oUse large adult blood pressure cuffs or thigh cuffs on patients with an upper-arm circumference greater than 34 cm.

·Be respectful when talking about the patient’s weight.

oWeigh patients in a private area and only when medically needed.

oRecord weight without comments.

·Offer well-care services.

oAllow enough time during office visits to provide well-care services.

·Promote healthy behaviors.

oAsk patients if they want to talk about weight loss. If they want to talk about losing weight‚ let them know that a weight loss of 5 to 7 percent of body weight may lower their chance of developing diabetes. Work with patients to establish realistic goals.

oStart small. Encourage patients to start with simple goals such as walking for 10 minutes‚ three times a day. Once they achieve this goal‚ they can build on it.

oOffer patients information and referrals to registered dietitians‚ other health providers‚ and support groups‚ as needed.

oPromote self-acceptance and encourage patients to lead full and active lives.

At last week’s mHealthcon, the soon-to-be-annual event that brings together mobile health entrepreneurs, marketers, patients, and investors to talk shop in New Brunswick, NJ, I couldn’t help but think, “Where is pharma?”

Yes, there were a couple of representatives from manufacturers like Bristol-Myers Squibb. But they were vastly outnumbered by their healthcare peers:

Managed care organizations

Large healthcare providers

Physicians and researchers

Mobile is potentially the greatest opportunity for pharma to break out of its innovation funk. And “The Healthcare City,” as New Brunswick bills itself, would have been a great place for pharma to stoke its creative fires—right in the industry’s backyard.

It’s not as if patients aren’t asking for mobile solutions …

“We have the opportunity to drive an ‘Arab Spring’ in healthcare,” said blogger Casey Quinlan, author of Cancer for Christmas and an outspoken patient advocate. Quinlan, diagnosed with breast cancer in 2007, said there were not enough tools available to help her manage her disease and treatment side effects.

“If there had been an app that would have helped me manage my neutropenia (low white blood cell count) and anemia (low red or total blood cell count),” Quinlan told the audience, “I would have easily paid a couple hundred dollars for it.”

Amy Gurowitz, who is launching a learning community for people with MS, said she surveyed her beta testers about their use of tracker apps. Only one person reported using one. “They didn’t even know that these tools are out there,” Gurowitz said, suggesting there is a market for such tools if they can be promoted effectively to patients.

It’s not as if pharma companies are ignoring mobile opportunities…

To be fair, pharma has produced a growing number of mobile apps and tools. (Quick plug: You can read about some mobile pharma case studies in an earlier blog post I co-wrote with digital buddy Megan Beardsley). Some have been built for patients, while most target healthcare providers.

Still, I’m not convinced that pharma is fully prepared for the coming mobile onslaught. And I’m not the only one.

At a conference break, I caught the attention of Paulo Machado, a leading voice in pharma innovation and the former Innovation Director at AstraZeneca. During our conversation, Paulo really helped crystallize pharma’s conundrum.

In essence, he said, pharma companies are manufacturers. And it’s much harder for manufacturers to evolve away from a product-centric mindset than it is for service providers—your payers, hospitals, clinics, and most other health organizations.

Paulo said that healthcare reform is driving service companies away from the fee-for-service model. “They actually have to run profitable businesses now,” he observed.

Translation: Payers, not pharma, may end up leading the charge into mobile health.

Any tool that helps patients improve outcomes and lower costs will be mission-critical

Sure enough, later in the day Michael Monson, SVP Performance & Innovation at the Visiting Nurse Service of New York (VNSNY), encouraged mobile health entrepreneurs to bring him innovative ideas… like, now.

Headquartered in Manhattan, VNSNY is the country’s largest not-for-profit home healthcare service. It is both a provider and a payer. Monson explained that innovation is a large component of the company’s strategic approach. As healthcare evolves in the US, mobile seems to be a major way forward.

“We really like using behavioral science,” Monson said, referencing partner Welldoc, which is running a mobile adherence pilot for VNSNY with diabetes patients. Welldoc was in the news recently when Ford announced a beta test in which diabetic drivers could “ask” their cars to check their blood glucose levels. The Ford beta is being powered by a Welldoc wireless health monitoring platform.

It’s innovations like these—“software devices that enhance consumers’ lives,” Monson said—that are going to power the future of mobile health.

Mobilization can work for pharma too

The economic rewards for innovation certainly favor companies like Monson’s. But I believe pharma also needs to stand up and put the industry’s significant weight behind mobile health initiatives. Apps would be the logical place to start—they are the most “product-like” side of mobile—and the FDA already issued guidance for health apps this summer.

For pharma innovators interested in going mobile, some next steps should include:

Familiarizing yourself with the FDA mobile app guidelines

Getting outside the pharma space

Download and use some of the mobile tools that other healthcare organizations have built

Look for parallels that could be applicable to branded/unbranded product marketing

Finally, challenge your agencies to think blue sky—have them bring their strongest ideas for mobile to the table, and explore opportunities to pilot in 2012.

One day. One conference. So many powerful ideas, my head is still spinning.

This year’s Social Health (SXSH) 2011 unconference in Philadelphia was one of my favorite healthcare events in recent memory. Kudos to the “industry-side” organizers, Shwen Gwee and Dana Lewis, and the “patient-side” organizers, Jenni Prokopy and Kerri Spalding (better known in social media circles as @ChronicBabe and @sixuntilme). They assembled a dynamic group of speakers who brought crisp presentations packed with good stuff to a diverse audience of healthcare marketers, physicians, patient advocates, wellness specialists, and others.

There are so many ways to parse what we learned, I could probably write 10 articles on Social Health. A few core themes in particular stuck with me; they are rich in implications for all who work in healthcare, pharma communications, and patient education. It’s going to take me a few blogs to digest it all for you. For starters:

Healthcare is entering a crisis of comprehension.

While drug patent expirations and hazy FDA guidance get all of the headlines, a larger issue will undoubtedly be whether health literacy impacts Washington’s goal of empowering patients with their own medical data. Todd Park, the chief technology officer of the US Department of Health and Human Services, excitedly shared the administration’s many data initiatives, including giving Bluebutton access to US veterans—more than 400,000 of whom have used the service to download e-copies of their health data. When you look at the actual documents produced and sent to vets—a sample is here—you’ll understand why I use the phrase “crisis of comprehension.” Consider this snippet:

Hearkens back to the days of teletype machines and ASCII printouts, doesn’t it? Imagine you’re the veteran to whom this data belongs. Or imagine you’re a caregiver hoping to learn more about your loved one’s medical history. Reading the above, should you panic? Should you look up coagulation tissue factor induced on WebMD? Call the doctor to find out why the result was “low”? Not worry about it because—whatever this all means—the result was “reported incorrectly"?

To his credit, Park told the audience that for matters of health literacy, he’s relying on us—the communicators, health educators, experts—to dress up this medically oriented data and “skin” it for the public’s view. If the supply of untethered data accelerates at the pace Park and others are projecting, a huge lag will open up between when health consumers receive it and when educational tools are built to help them understand it. Our job, then, is to analyze this growing swell of patient data initiatives and anticipate the health literacy stumbling blocks. Making patient data meaningful to everyday people struggling with medical conditions is a great challenge and opportunity.

Or, in the words of Park at SXSH: “I think this is the greatest opportunity since the Internet itself.”

We'd better get moving.

Jeff Greene will write additional articles on Social Health (SXSH) for the HealthEd Blog.

With the release of the 2010 Dietary Guidelines for Americans, it is apparent that a shift is occurring in the approach to address the nation’s obesity epidemic. Differing from previous dietary guidelines, which focused solely on nutrition intervention, the new guidelines take a holistic approach to improving health outcomes. The approach both is refreshing and helps to set a new standard for improving the nation’s nutrition status.

With a newfound focus on health promotion and chronic disease risk reduction, the updated guidelines reflect the importance of establishing healthy eating patterns and physical activity behaviors as preventive measures to combat obesity.

As stated in the guidelines:

The ultimate goal…is to improve the health of our Nation’s current and future generations by facilitating and promoting healthy eating and physical activity choices so that these behaviors become the norm among all individuals.

Creating a new norm for the American population will undoubtedly be an arduous task. However, there are clear indications that the dietary guidelines are fundamentally headed in the right direction.

From a health education perspective, the integration and development of the dietary guideline recommendations were based upon Social-Ecological Model (Dahlberg & Krug, 2002). This is the primary indication of how the guidelines can help Americans to make healthier choices. Basing the guidelines on the Social-Ecological model allows for the development of strategies that focus on the relationship among behavioral, environmental, and social ecological influences that can lead to effective and sustainable behavioral and lifestyle modifications. This is very telling because it demonstrates that to improve the nation’s nutrition standards, it is vital to understand that diet and exercise are not the sole contributors to the problem; rather, the problem results from an interplay of many health influences.

The emphasis on and priority for improving the nation’s health now rests with transforming the way Americans view nutrition. Leveraging health education principles—by incorporating behavior change models and providing useful tools to support this change—can do more than inform and guide Americans through this nutrition transformation. Health education helps to ensure that Americans can understand the basic nutrition information and feel empowered to take action to improve their health in ways they may have never imagined. With action comes the shift that the 2010 Dietary Guidelines for Americans aim to achieve—improved health for the nation.